Eligibility for Alkermes-Sponsored Co-pay Savings: This offer is only available to commercially insured patients 18 years or older with a LYBALVI prescription that is consistent with the Prescribing Information. Health plan requirements for a prior authorization and/or step therapies must be attempted prior to using this co-pay offer. This offer is not available to patients who are enrolled in, or covered by, any local, state, federal or other government program that pays for any portion of medication costs, including but not limited to Medicare, including Medicare Part D or Medicare Advantage plans; Medicaid, including Medicaid Managed Care and Alternative Benefit Plans under the Affordable Care Act; Medigap; VA; DOD; TRICARE; or a residential correctional program. Patients who become eligible for any government program that pays for any portion of medication costs will no longer be eligible for this program.
To the Patient: Present this card and prescription for LYBALVI to the pharmacist to participate in this program. When using this card, you certify that you understand the program rules and terms and conditions and that you meet, or are the legal guardian of a patient who meets, the program eligibility requirements. This offer is not available to patients who are enrolled in, or covered by, any local, state, federal or other government program that pays for any portion of medication costs, including but not limited to Medicare, including Medicare Part D or Medicare Advantage plans; Medicaid, including Medicaid Managed Care and Alternative Benefit Plans under the Affordable Care Act; Medigap; VA; DOD; TRICARE; or a residential correctional program. Patients who become eligible for any government program that pays for any portion of medication costs will no longer be eligible for this program. For questions about your eligibility or benefits, if your insurance has changed, or if you wish to discontinue your participation, call the LYBALVI Co-pay Savings Program at 1-855-820-9624 (8:00 AM-8:00 PM EST, Monday-Friday).
To the Pharmacist: When using this card, you certify that you have not submitted and will not submit a claim for reimbursement under any local, state, federal, or other government program for this prescription. Submit transaction to McKesson Corporation using BIN 610524. Submit commercial insurance as primary coverage, input co-pay savings card information as secondary coverage, and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response. Acceptance of this card and your submission of claims for LYBALVI are subject to the LoyaltyScript® Program terms and conditions posted at www.mckesson.com/mprstnc. Patient is not eligible if patient is enrolled in, or covered by, any local, state, federal, or other government program that pays for any portion of medication costs, including but not limited to Medicare, Medicaid, Medigap, VA, DOD, TRICARE, or a residential correctional program. The LYBALVI Co-pay Savings Program card is not valid for use with any other prescription drug discount or cash cards for LYBALVI. Claims submitted utilizing the program are subject to audit or validation. For questions regarding setup, claim transmission, patient eligibility, or other issues, call the LoyaltyScript® Program for the LYBALVI Co-pay Savings Program at 1‑855‑820‑9624 (8:00 AM-8:00 PM EST, Monday-Friday).
Authorization and Additional Terms of Use: By using this offer, you authorize the LoyaltyScript® Program to share your prescription information with CoverMyMeds so that CoverMyMeds may contact your healthcare provider to request submission of information to support coverage of your LYBALVI prescription by your health insurance plan. This offer is not conditioned on any past, present, or future purchase, including refills. Alkermes reserves the right to rescind, revoke, or amend this offer, program eligibility, and requirements at any time without notice. This offer is limited to one per patient, may not be used with any other offer, is not transferable, and may not be sold, purchased or traded, or offered for sale, purchase, or trade. Void where prohibited by law. Program may be subject to plan benefit design requirements. Program Administrator or its designee will have the right upon reasonable prior written notice, during normal business hours, and subject to applicable law, to audit compliance with this program.
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